Staff Perspective: The Therapeutic Relationship
While we may not like to admit it, most of us are drawn to our work because we like working with others. We like helping people navigate their problems and come through healthier, happier, and more engaged in life. However, there are some patients that make us cringe… make us secretly hope for a no-show…and make us count the minutes during the session if they do show. Fortunately, these patients are few and far between, but it’s important to remember that even with our most difficult patients, there can be important lessons to be learned.
Early into my deployment, I was referred a patient by a psychiatrist I very much respected. She asked me to “put eyes on this guy and tell me what you think… something is off with him and I just can’t put my finger on it.” She wondered if there might be some psychotic processes going on and was concerned about safety.
I didn't like the guy from the get-go. For lack of a more professional description, he was creepy. He didn't make eye contact, talked in a whisper, talked in a very expansive philosophical manner and became agitated with any direct questioning. As creepy as he was, I wasn't getting the psychotic vibe from him. No matter what I asked him or how I asked him, he had reasonable explanations for all of his behaviors. I reviewed his responses to the MMPI-2 (Minnesota Multiphasic Personality Inventory) with him and he did acknowledge hearing voices, however explained that the voice was the voice of God. He explained that he was extremely religious and hoped to become a church leader upon his return home. He indicated that his entire family was religious and often talked about seeing angels or spirits.
Despite his explanations, this guy still gave me the chills. I literally had the thought during my first session with him that he could reach across the room, snap my neck and not even raise his heartbeat. BUT he wasn't endorsing ANY antisocial traits or patterns of behaviors. He was just scary and I couldn't wait to get him out of my office. He was performing his job well at work, no homicidal or suicidal ideation and he wasn't psychotic. I didn't have any reason to contact his Command. I remember being really disturbed when he left my office, unsure what I was missing.
Over the next two weeks, I saw him in the clinic several times. He was always polite and acknowledged my presence, despite never making eye contact with me and always speaking in an angry forced tone. I asked him once how he was doing and he replied, "Just trying to get through it all, ma'am… one day at a time." I tried to be empathic and encouraging, “Keep up the good work and I’ll see you later this week.” The psychiatrist saw him once more and said that he was doing somewhat better on the Prozac, but she was still getting the creepy vibe from him. Later in the week, when I saw him on my schedule, my first reaction was, "Shit." All morning long, I had hoped that he would be a no-show. No luck. He arrived to the appointment 25 minutes early, sat rigidly in the chair in the waiting room and stared at the floor. I was on my way to a meeting and asked him if he needed to be seen by one of our technicians or if he could wait 30 minutes until I returned. He chose to wait. When I entered the clinic 30 minutes later, he had not moved one inch. The technicians said he had sat in that same rigid position the entire time I was gone.
Immediately upon sitting down in my office, he stated, "I want to initiate a Command Directed Evaluation." Upon further questioning, he indicated he NEEDED the evaluation for himself because he was “a danger to others.” Now, I have to tell you - because this guy creeps me out and waxes on philosophically, I was prepared to hear just about anything from him with half-hearted interest.
He proceeded to tell me he had a very methodical, clear plan and intent to kill two individuals in his Chain of Command. As he described this to me, he started to shake in what I can only imagine as rage. He told me, "Be clear about this doc... I have no intention of hurting myself. But I am going to kill someone today." He said it in such a creepy, sinister, and evil manner that every one of my hairs stood up on my body. He then said, "I am going to kill SM X and SM Y and I'm going to take out as many people in the office before someone shoots and kills me." He indicated that he was on his way to his office to carry through with his plan, but remembered something I had said in that first session that made him reconsider his plan. For a split-second, I considered him to be malingering to get out of theater. Regardless, his threat was clear and he had intent and plan. Game on.
“What you're telling me SGT is that you're feeling out of control and I need to make sure that you're safe and that everyone around you is safe. I'm going to have to contact your Command now so that we can all get on the same page for getting you the help you need. I know that this feeling out of control is scary. We're going to make sure you get the help you need." While in my head, I'm thinking, “Please don't let me be the one you kill today... please don't kill me...please don't kill me.”
I call his Command and speak with BOTH his intended targets (per Tarasoff) and recommend that we get this guy out of theater immediately. He is just so creepy and giving off bad vibes right and left, I didn't think there was a single thing we could do in theater to manage his risk. Luckily, his Command agreed. According to reports received within the past 24 hours, this individual had been acting erratically, cleaning and charging his weapon repeatedly both in the workspace and in his quarters, as well as referencing bible quotes to his co-workers. Given all of the concern, we were able to move pretty quickly and, within 12 hours, this individual was on an aircraft destined for Landstuhl, Germany for further evaluation.
I returned back to the clinic to finish up my paperwork and found an email waiting for me from the soldier's Command that detailed what was found in his room. Inside a room that appeared to be recently torn apart, a note was written on the wall in marker apologizing to his daughter and wife for what he was about to do and confessing his love for them, several death notes nailed to his wall, his own hand-written obituary with that day’s date on it, an entire wall of hand-written bible scripture written in Sharpie marker, and several threatening statements toward the two identified intended victims. Additionally, all of his personal pictures had been destroyed.
Later that day, as everyone was breathing a sigh of relief that this potential tragedy had been averted, it occurred to me that he never told me what I had said to him during that first session that was so meaningful for him that day. It struck me, even though I was unable to feel connected to this patient (other than through fear), he obviously felt some kind of connection to me, or at least to something I had said when we first met. How much of a difference that actually made, I’ll never know. I do, however, know that therapy can be a very powerful tool and that, more often than not, there is more going on than what is on the surface!
Dr. Brandy Hellman is a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology at Walter Reed National Military Medical Center in Bethesda, MD.
While we may not like to admit it, most of us are drawn to our work because we like working with others. We like helping people navigate their problems and come through healthier, happier, and more engaged in life. However, there are some patients that make us cringe… make us secretly hope for a no-show…and make us count the minutes during the session if they do show. Fortunately, these patients are few and far between, but it’s important to remember that even with our most difficult patients, there can be important lessons to be learned.
Early into my deployment, I was referred a patient by a psychiatrist I very much respected. She asked me to “put eyes on this guy and tell me what you think… something is off with him and I just can’t put my finger on it.” She wondered if there might be some psychotic processes going on and was concerned about safety.
I didn't like the guy from the get-go. For lack of a more professional description, he was creepy. He didn't make eye contact, talked in a whisper, talked in a very expansive philosophical manner and became agitated with any direct questioning. As creepy as he was, I wasn't getting the psychotic vibe from him. No matter what I asked him or how I asked him, he had reasonable explanations for all of his behaviors. I reviewed his responses to the MMPI-2 (Minnesota Multiphasic Personality Inventory) with him and he did acknowledge hearing voices, however explained that the voice was the voice of God. He explained that he was extremely religious and hoped to become a church leader upon his return home. He indicated that his entire family was religious and often talked about seeing angels or spirits.
Despite his explanations, this guy still gave me the chills. I literally had the thought during my first session with him that he could reach across the room, snap my neck and not even raise his heartbeat. BUT he wasn't endorsing ANY antisocial traits or patterns of behaviors. He was just scary and I couldn't wait to get him out of my office. He was performing his job well at work, no homicidal or suicidal ideation and he wasn't psychotic. I didn't have any reason to contact his Command. I remember being really disturbed when he left my office, unsure what I was missing.
Over the next two weeks, I saw him in the clinic several times. He was always polite and acknowledged my presence, despite never making eye contact with me and always speaking in an angry forced tone. I asked him once how he was doing and he replied, "Just trying to get through it all, ma'am… one day at a time." I tried to be empathic and encouraging, “Keep up the good work and I’ll see you later this week.” The psychiatrist saw him once more and said that he was doing somewhat better on the Prozac, but she was still getting the creepy vibe from him. Later in the week, when I saw him on my schedule, my first reaction was, "Shit." All morning long, I had hoped that he would be a no-show. No luck. He arrived to the appointment 25 minutes early, sat rigidly in the chair in the waiting room and stared at the floor. I was on my way to a meeting and asked him if he needed to be seen by one of our technicians or if he could wait 30 minutes until I returned. He chose to wait. When I entered the clinic 30 minutes later, he had not moved one inch. The technicians said he had sat in that same rigid position the entire time I was gone.
Immediately upon sitting down in my office, he stated, "I want to initiate a Command Directed Evaluation." Upon further questioning, he indicated he NEEDED the evaluation for himself because he was “a danger to others.” Now, I have to tell you - because this guy creeps me out and waxes on philosophically, I was prepared to hear just about anything from him with half-hearted interest.
He proceeded to tell me he had a very methodical, clear plan and intent to kill two individuals in his Chain of Command. As he described this to me, he started to shake in what I can only imagine as rage. He told me, "Be clear about this doc... I have no intention of hurting myself. But I am going to kill someone today." He said it in such a creepy, sinister, and evil manner that every one of my hairs stood up on my body. He then said, "I am going to kill SM X and SM Y and I'm going to take out as many people in the office before someone shoots and kills me." He indicated that he was on his way to his office to carry through with his plan, but remembered something I had said in that first session that made him reconsider his plan. For a split-second, I considered him to be malingering to get out of theater. Regardless, his threat was clear and he had intent and plan. Game on.
“What you're telling me SGT is that you're feeling out of control and I need to make sure that you're safe and that everyone around you is safe. I'm going to have to contact your Command now so that we can all get on the same page for getting you the help you need. I know that this feeling out of control is scary. We're going to make sure you get the help you need." While in my head, I'm thinking, “Please don't let me be the one you kill today... please don't kill me...please don't kill me.”
I call his Command and speak with BOTH his intended targets (per Tarasoff) and recommend that we get this guy out of theater immediately. He is just so creepy and giving off bad vibes right and left, I didn't think there was a single thing we could do in theater to manage his risk. Luckily, his Command agreed. According to reports received within the past 24 hours, this individual had been acting erratically, cleaning and charging his weapon repeatedly both in the workspace and in his quarters, as well as referencing bible quotes to his co-workers. Given all of the concern, we were able to move pretty quickly and, within 12 hours, this individual was on an aircraft destined for Landstuhl, Germany for further evaluation.
I returned back to the clinic to finish up my paperwork and found an email waiting for me from the soldier's Command that detailed what was found in his room. Inside a room that appeared to be recently torn apart, a note was written on the wall in marker apologizing to his daughter and wife for what he was about to do and confessing his love for them, several death notes nailed to his wall, his own hand-written obituary with that day’s date on it, an entire wall of hand-written bible scripture written in Sharpie marker, and several threatening statements toward the two identified intended victims. Additionally, all of his personal pictures had been destroyed.
Later that day, as everyone was breathing a sigh of relief that this potential tragedy had been averted, it occurred to me that he never told me what I had said to him during that first session that was so meaningful for him that day. It struck me, even though I was unable to feel connected to this patient (other than through fear), he obviously felt some kind of connection to me, or at least to something I had said when we first met. How much of a difference that actually made, I’ll never know. I do, however, know that therapy can be a very powerful tool and that, more often than not, there is more going on than what is on the surface!
Dr. Brandy Hellman is a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology at Walter Reed National Military Medical Center in Bethesda, MD.
Comments
Mrogers replied on Permalink
Powerful Story
Powerful personal narrative on the importance of the therapeutic relationship.Thank you.